Documents to be submitted at the time of production of hard copy of the bill for

reimbursement of assessment cost under PMKVY CSSM

(One bill should be submitted for one batch only)

Sl.
No Particulars Documents
.
To,
The Project Director,
1. Covering letter Paschim Banga Society For Skill Development (PBSSD)
C/o Directorate of Industrial Training, West Bengal
Government of West Bengal
Karigori Bhawan , Rajarhat, New Town, Kolkata – 700160
2. Bill regarding Format of Annexure I, Submit in Triplicate copy and Signature in
reimbursement of fees blue ink, date & Seal of Head of AB is essential.
3. Assessment Cost Claim Format of Assessment Cost Claim Sheet, Annexure III
Sheet

4. Result Sheet Copy of Portal Result Sheet

Portal Attendance Sheet
5. with Candidate and Submit the portal Assessment list with student signature and duly
Assessor Signature & date signed & stamp by assessor.
of Assessment, with Office
seal
6. Name & Qualification of Format of Name & Qualification of Assessor, Annexure II
Assessor
7. E-payment Form Format of E-payment, Annexure IV

8.  All photocopies should be certify by Head of the AB, Signature, date and seal of AB
 Page no. should be given in Descending order on Top of each Pages.
 Annexure - I
(In Triplicate)
Bill for the Reimbursement of Assessment Cost Claim for courses under the PMKVY CSSM
(To be filled in by the registered AB)
1.Name of Scheme in which
Assessment Imparted
2. Registration No. of AB
3. Name of AB & HQ. Postal
Address
4. Name of Region Head of
the AB, Designation and
Contact details i.e. Mobile
No. and E-mail ID
5. Name of Head of the AB
Designation and Contact
details i.e. Mobile No. and E-
mail ID
Sl. Course
Course Name
6.Name of Courses & Course no. Code
Codes

Sl. Course No. of No. of

7.Total number of Trainees no. Code Appeared Trainees Passed Trainees
Appeared and Passed for
the examination
Sl.
ABN Batch No. Date of Assessment
no.
8. Assessment Batch No.
and Date of Assessment
Assessed Assessment
Course Amount
Candidate Fees
9.Total amount claimed in Code (a) × (b)
(a) (b)
this bill for trainees

Total Claim Amount

10. Name of the Bank
11. Name of Account
12. Name of Bank Branch
& Code
13. Account No.
14. IFSC Code
15. MICR Code

 It is Certified that-
1. The assessment has been done in accordance with the prescribed assessment
methodology under SDIS.
2. Claims have been submitted in respect of those who have successfully assessed the
test conducted by us and are eligible for reimbursement.
3. Claims as per this bill has not been drawn / made previously.

__________________________________________________
Date: Full Signature of the Authorized Person
Of the Assessing Body
 (In Letter head of AB)

Annexure – II

Format of Name & Qualification of Assessor

Name of the
TP& Address
Sl.
Name Qualification Sector Course Code Where
No.
Assessment
was done

Date:
Signature of the Authorized Person of the Assessing Body

Name :
Designation :
Mobile No.
Email :
Office Seal:
 Annexure III

Assessment Cost Reimbursement to Assessing Body

Name of Scheme of in which
Assessment Imparted
Registration No. of the Assessing  
Body
Name of the Assessing Body  

Sector and Course Code  

Batch Type  
No of Candidates assessed  
Training Batch No. (PMKVY CSSM)  
Duration of Module (in hours)  
Training imparted from  
(dd/mm/yyyy) to
(dd/mm/yyyy)
Assessment Batch No  
Assessment Date  
Testing Center/TP  
State  
Total amount claimed in this bill for  
assessed candidates
It is certified that:

1. Claim has been submitted in respect of those trainees who have been assessed by
Assessing Body.

2. Claim as per this batch has not been drawn/made previously.

Signature:

Name of the Head:

Assessing Body:
 ANNEXURE-IV

Mandate by Payee for e-Payment

Date:
___.____._______

To
The Project Director
Paschim Banga Society For Skill Development
KarigariBhawan,
B/7, Action Area-III, NewTown ,Rajarhat,
Kolkata-700160

Subject: Payment through electronic mode.

Sir,

We are giving option for availing the facility of e-Payment. Kindly arrange to remit
the amount to my/our Bank Account hereinafter. The details of my/our particulars are
furnished below:

1. (a) Name of the Claimant/ Payee/Recipient: (Capital letters)

(b) Address:

(c) Contact No. Land Line: Mobile :

(d) E-mail:

(e) ID No.: Nature of ID:

2. (a) Name of Bank:

(b) Name of Branch with Bank Branch Code:

(c) Account Type:

(d) Bank Account No. [CBS allotted a/c. No.]

(e) Branch IFSC [11-

digits]:

(f) Branch MICR [9-

digits]:
The Bank particulars furnished above is correct and true.

We hereby declare that I/we and my/our heirs and successors accept the liability of
making good to Government the overpayment, if any, made to me/us under the scheme.

I/we hereby authorise ------------------ (name of the Branch) of the --------------------

(Name of Bank) to receive amount on my/our behalf for credit to my/our account as
stated above and further authorise that the receipt of credit given by the bank for the
amount of my/our account shall be treated as legal quittance.

Yours faithfully,

Signature of the Head of office

(Office Seal)

(To be accepted by the Head of Office)

Date: Signature of the Head of office

(Office Seal)

B. (a) ID No. & Nature of ID: ID No. (i) For individual: It should be Voter Card, Adhar
Card or PAN Card or any other Identity card issued by the State Government/Central
Government/ Government Autonomous Bodies/ Local Bodies, (ii) For Autonomous
Body/Firm/ Company: Registration No. or PAN / TAN Number or Trade License.

(b) Verification of Bank Particular: Copy of the 1st page of the Pass-Book along with a
copy of cancelled cheque or certified by the concerned Bank-branch.